Balance and PostureAndrew L. McDonough

What is Balance? Technically defined as the ability to

maintain the center-of-gravity (COG) of an object within its base-of-support (BOS)

What is Posture? The stereotypical alignment of body/limb

segments– Types

» Standing (static)» Walking - running (dynamic)» Sitting» Lying» Lifting

Relationship - Balance & Posture Postural alignment (and the

changes/adjustments made due to perturbations) is the way balance is maintained

Maintaining the COG within the BOS– If this relationship isn’t maintained then a

system will be unbalanced

Base of Support

x

H-H

TM-L TM-R

x - Vertical projection of COG

Walking

x

Static Dynamic

Transition - Static to Dynamic BOS

Heel-to-heel distance will decrease– Feet come together toward midline

Toe-to-midline distance will decrease– Reflects “toe-in”

Overall effect - BOS narrows

The Effect of a Narrowed BOS Chances of COG falling within BOS

decrease– Subject becomes less (un-) balanced

COG moves forward of BOS - precursor event to walking– Foot will be advanced to extend the dynamic

BOS

Center-of-Gravity The point about which the mass is evenly

distributed The balance point If an object is symmetrically loaded the

COG will be at the geometric center

Center of Gravity of Human Limbs and Segments

Limbs/segments are usually asymmetrically loaded

COG tends to be “off-center”– Closer to the “heavier end”

Sources– Dempster (1955)– Braune and Fischer (1889)– Winter (1990s)

Dempster Subjects were 150 lbs. males (astronauts -

NASA) COG located at a point as a percentage of

total limb length

KneeAnkle

43.3% 56.7%

Total limb length

Location of COG Entire body Suprapedal mass Suprafemoral mass HAT Head

S1 - S2

ASIS Umbilicus Xiphoid process Occiput

Example: Change in the Location of the COG of Body - Right Unilateral AK Amputee

COG will shift upward and to the left

Question: How will this change affect the patient’s perception of balance?

Answer: Profoundly!

General Rule As COG shifts upward the object/subject

becomes more “top-heavy” Increases the “tendency to be over-thrown”

Moment arm Moment arm

Role of Anti-gravity Postural Muscles

Generate torque across joints to: “Resist the tendency to be over-thrown”– Keep limbs, joints, body segments in proper

relationship to one another so that the COG falls within the BOS

Some Examples - Questions What happens to the COG & BOS in:

– Someone walking along a sidewalks and encounters a patch of ice

– The toddler just beginning to walk– The surfer coming down off of a wave– The tight-rope walker who loses her balance

A Systems Model of Balance1

1Courtesy of Sandra Rader, PT, Clinical Specialist

Stability & Balance Result of interaction of many variables (see model) Limits of Stability - distance in any direction a

subject can lean away from mid-line without altering the BOS

Determinants:– Firmness of BOS– Strength and speed of muscular responses– Range: 80 anteriorly; 40 posteriorly

Limits of Stability

Model ComponentsMusculoskeletal System

ROM of joints Strength/power Sensation

– Pain– Reflexive inhibition

Abnormal muscle tone– Hypertonia (spasticity)– Hypotonia

Model ComponentsGoal/Task Orientation

What is the nature of the activity or task?

What are the goals or objectives?

Model ComponentsCentral Set

Past experience may have created “motor programs”

CNS may select a motor program to fine-tune a motor experience

Model ComponentsEnvironmental Organization

Nature of contact surface– Texture– Moving or stationary?

Nature of the “surrounds”– Regulatory features of

the environment (Gentile)

Model ComponentsMotor Coordination

Movement strategies– Based on repertoire of

existing motor programs

Feedback & feedforward control

Adjustment/tuning of strategies

Strategies to Maintain/Restore Balance

Ankle Hip Stepping Suspensory

Strategies are automatic and occur 85 to 90 msec after the perception of instability is realized

Ankle Strategy Used when perturbation

is – Slow– Low amplitude

Contact surface firm, wide and longer than foot

Muscles recruited distal-to-proximal

Head movements in-phase with hips

Ankle Strategy

Hip Strategy Used when

perturbation is fast or large amplitude

Surface is unstable or shorter than feet

Muscles recruited proximal-to-distal

Head movement out-of-phase with hips

Hip Strategy

Stepping Strategy Used to prevent a fall Used when

perturbations are fast or large amplitude -or- when other strategies fail

BOS moves to “catch up with” BOS

Suspensory Strategy Forward bend of trunk

with hip/knee flexion - may progress to a squatting position

COG lowered

Model ComponentsSensory Organization

Balance/postural control via three systems:– Somatosensory– Visual– Vestibular

Somatosensory System Dominant sensory

system Provides fast input Reports information

– Self-to-(supporting) surface

– Relation of one limb/segment to another

Components– Muscle spindle

» Muscle length» Rate of change

– GTOs (NTOs)» Monitor tension

– Joint receptors» Mechanoreceptors

– Cutaneous receptors

Visual System Reports information

– Self-to-(supporting) surface

– Head position» Keep visual gaze

parallel with horizon

Subject to distortion

Components– Eye and visual tracts– Thalamic nuclei– Visual cortex

» Projections to parietal and temporal lobes

Vestibular System

Not under conscious control

Assesses movements of head and body relative to gravity and the horizon (with visual system)

Resolves inter-sensory system conflicts

Gaze stablization

Components– Cerebellum– Projections to:

» Brain stem» Ear

Sensory-Motor Integration

SomatosensoryVestibularVisual

Eye Movements

Postural Movements

10 Processor

20 ProcessorCerebellum

Motoneurons

Sensory Input Processing Motor Response

What is Posture? The stereotypical alignment of body/limb

segments– Types

» Standing (static)» Walking - running (dynamic)» Sitting» Lying» Lifting

Posture Position or attitude of the body ‘Postural sets’ are a means of maintaining

balance as we’ve defined it– Standing (static)– Walking - running (dynamic)– Sitting– Lying– Lifting

What Does Posture Do for Us?

Allows body to maintain upright alignment Permits efficient movement patterns Allows joints to be loaded symmetrically

– Decreases or distributes loads on» Ligaments and other CT» Muscle» Cartilage and bone

‘Good posture’ usually results in the least amount of energy expended

Erect Standing Posture & the ‘Gravity Line’ (Sagittal Analysis) ‘Gravity line falls:

– Forward of ankle– Through or forward of the

knee– Through of behind the hip

(common hip axis)– Behind or through thoracic

spine– Through acromium– Through or forward of

atlanto-occipital jt.

Erect Standing Posture & the ‘Gravity Line’ (Frontal Analysis)

Gravity line falls:– Symmetrically between two feet– Through the umbilicus– Through the xiphoid process– Through the chin & nose– Between the eyes

The ‘Gravity Line and Anti-gravity Muscles (Sagittal Plane) Gravity line falls:

– Forward of ankle– Through or forward of the

knee– Through of behind the hip

(common hip axis)– Behind or through thoracic

spine– Through acromium– Through or forward of

atlanto-occipital

Anti-gravity muscle:– Gastroc-soleus– Quadriceps

– Hip extensors

– Paraspinals

– Neck extensors

Relaxed vs. ‘Military’ Standing Posture

The ‘Military Posture’ requires ~30% more energy expenditure compared with a more relaxed upright standing posture

Sitting Posture Disc patients often

cannot sit– Increased intra-disc

pressure compared with standing

– Often loss of lordotic curve - may reverse leading to asymmetrical disc loading

Sitting Posture - Elements Back against chair

– Lumbar support Seat height

– Don’t allow feet to dangle or knees too high

Seat length– Too long forces loss of

lordosis Feet flat with hips &

knees at ~900

Forearms supported

Lying (Sleeping) Posture Elements

– Firm mattress for support– Not too many pillows -

Maybe none– Lying flat on back may

decrease lordosis– Hook-lying may preserve

lordosis– Side-lying may be more

comfortable

‘Lifting Posture’ - PT’s vs. Patient’s

Control COG (PT’s & patient’s) vs. BOS– Don’t over-extend while reaching for patient

Load LEs symmetrically - NO rotation! Maintain correct spinal curvature - especially

lumbar spine– Spine should NOT be straight - maintain lordosis– Think about a ‘power lifter’

Leverage vs. brute force

Remember... Get Help!

Remember... Get Help!

Most SuperPTs have LBP & disc disease!